[Question #2973] Follow up to Question 2932

42 months ago
Hi Dr HHH, 

I wish I didn’t need your continued guidance but I need some direction. Medical care is extremely sparce where I live and not the best, so forums like this are invaluable. 
To recap: 
Protected sex on 10/13 and 10/25; unprotected cunnilingus 
10/26 noticed painful lymph node on left side under jaw. Only symptom until 11/1 when 2nd lymph node popped up under right side of jaw. Went to pcp on 11/2 w/ low grade fever and sore throat - thought i had an ear infection. Per your advice , saw him again on 11/7. He examined my throat and said he saw nothing that looked like herpes. I felt a little bit better but spiked a fever of 103 on 11/8-11/10. Throat became very sore so he sent me to an ent. Ent became concerned bc he saw a “mass” at the base of my tongue. Ordered a ct scan. Had follow up with him 11/13 and swelling had gone down but suggested my lingual tonsils were very swollen and what I was seeing was “exudate” due to a virus ? Not ulcers. 

Mono and strep tests were both negative . 

Neither physician would do a throat culture (don’t get me started) and both dismissed herpes with visual examination. In reading through things on the web I truly see no other explanation. I’m certain it is hsv 1 or 2. 

My questions : 

1) would hsv 1 be more or less likely and would they present differently orally (ie would 2 be more severe than one, etc) ?

2) I have had no Genital symptoms, so is it safe to assume to condom did it’s job? I’ve read that a few months post onset , I will have immunity genitally if it wasn’t acquired. Is that correct? 

3) my throat is largely healed and my pcp couldn’t find any ulcers to swab (and he’s out of town). Should i just wait for the 3 month mark and do an igg test, avoiding oral sex in the meantime. 

4) I did an oraquick test at 26 days that was negative. I realize this isn’t perfect, but given my symptoms, is it safe to rule out hiv ? 
Edward W. Hook M.D.
Edward W. Hook M.D.
42 months ago
 Welcome back to our forum. On this occasion I happen to pick up your question. Dr. Handsfield has already mentioned we answer questions interchangeably and typically completely agree with one another. In preparing to answer this question I have reviewed your extensive exchange with Dr. Handsfield about a week ago. I agree with all he said, i.e.  That all things being equal, and considering the fact that your partner had a similar illness, that this is more likely to be one of the every day, run-of-the-mill viral sore throat that people get from time to time rather than a sexually-transmitted infection of any sort. While herpes pharyngitis is a possibility I, like Dr. Handsfield, suspect that the risk of  that is low.   Also like Dr. Handsfield I am confident that this was not HIV.   With this preliminary statement I will now go on and answer your specific questions. 

1.   In the unlikely circumstance that this is oral herpes I would expect the possibility of this being oral HSV-1 to be somewhat higher than the risk of oral HSV-2. This of course presumes that during your encounter you and your partner also kissed as well as engaging in cunnilingus and protected genital sexual activities.  As Dr. Handsfield mentioned, HSV-1 and HSV-2 are clinically indistinguishable.

2.   Your symptoms are limited to your throat. In the absence of genital symptoms I would not worry about having acquired genital herpes. It is most unusual for herpes infections to occur at two sites simultaneously. 

3.   At this point with your pharyngeal symptoms having resolved, I see a little benefit from a throat swab for herpes. On the other hand Dr. Handsfield also suggested that you get a baseline IgG blood test for HSV-1 and -2 and I agree with this.  I would test both immediately and several months from now. 

4.   Like Dr. Handsfield I have a little concerned that this could be HIV related. While and or a quick test at four weeks is not completely sensitive in the context of your exposure I see no reason for further HIV testing related to this.    

 To summarize then, at this point as you try to sort out what was the cause of your sore throat, our major recommendation would be to get a blood test for herpes at this time and again in several months. Depending on the results this may be helpful in determining what happened. On the other hand if these tests are negative, the most likely outcome is  that you happened to get a particularly severe viral sore throat coincidently several weeks after the encounters you have described. 

I hope these comments are helpful.  EWH
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41 months ago
Hi Dr. Hook - 

Thank you for your last reply. These will be my last questions until I post my test IGG results.  

1. Dr Handsfield became increasingly concerned that this may Be herpes after I mentioned an ulcer at the back of my throat.  At the time My PCP said it was NOT a herpes ulcer (which is why he wouldn’t swab it) and that same spot in my mouth is still persisting with no change almost 25 days later. I’m thinking it could be a mucocelle? Is it safe to assume that what I thought was an ulcer could be something superficial (as most herpes lesions would have healed by now?) 

2. My biggest concern for herpes was the high fever and tender lymph nodes in my neck. As mentioned I had one tender node under my jaw on the left side before a second one popped up a week later on the right side. About two days later (so 9 days after the initial node)  is when the fever / night sweats began. These symptoms were very unusual and my fever reached 103 for a few days. Also there was no nasal congestion etc - just a swollen throat (which resulted in lingual tonsillitis ) - I’m still having some ear and jaw pain almost a month later from my initial symptom. In researching it seems only a few viruses (mono, herpes, HIV, CMV) or strep can cause such severe symptoms. Are there other viruses that can cause these severe symptoms (namely the high fever and night sweats) that could be adenoviruses or rhino viruses? I was negative for strep, flu and mono. 

3. I took a 4th generation lab based HIV test last Tuesday (so 35 days / 26 days) from my last exposures. It was negative. I know this wasn’t a major concern but do you feel that is more conclusive than the orasure test? 
Edward W. Hook M.D.
Edward W. Hook M.D.
41 months ago
thanks for your follow-up.  The additional information is helpful.

1.  If the lesion in your throat (I would not call it an ulcer any longer given your evolving description through no fault of your own) were due to HSV, it would have healed some time ago.  Thus this makes the likelihood that this entire event was due to herpes less likely.  OTOH, it is still worth ruling out and I am pleased that you have gotten a baseline HSV IgG test.  it will be interesting to see what it shows. 

2.  A vast number of viruses, many of which are not routinely tested for, could cause this sort of sore throat and would be expected to be accompanied by swollen lymph nodes. 

3.  A 26 day combination HIV antigen/antibody test is over 98% conclusive.  Such tests are totally conclusive at 42 days (6 weeks).  In your situation, I would be entirely confident that this was not HIV and would not feel the need for additional testing. 

Hope this helps.  Interested to hear of your HSV IgG test results.  EWH
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